Arkansas Health Care Reform Task Force: TSG Status Update # 4

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Proprietary and Confidential

Arkansas Health Care Reform Task Force: TSG Status Update # 4Arkansas Medicaid Long Term Care, Developmentally Disabled, Waiting List Cost Data, and facts about Community First Choice option

September 16, 2015

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Executive Summary• Costs of care for the Long Term Supports and Services (LTSS)

(Aged, Blind and Disabled (ABD), including Behavioral Health and all associated medical (Halo)) account for 74% of traditional Medicaid, yet fall outside Person-Centered Medical Home or Episodes of Care

• Arkansas places heavy reliance on both elder and DD institutional care, which even including halo costs is 2-3 times the cost of Home and Community Based Care (HCBC) alternatives

• RSPMI is heavily used by a few beneficiaries who claim over $100 a day, for a total of $31.5MM. This does not reduce inpatient (IP) Psych claims

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ABD Costs Including Halo Are 74% of Traditional Medicaid

Direct Program Costs Halo Effect Total Percent of

Claims

Elderly $989,580,886 $163,729,046 $1,153,309,933 29%

Developmentally Disabled $723,493,917 $183,455,886 $906,949,803 23%

Behavioral Health $464,686,509 $433,988,499 $898,675,008 22%

Sum of Aged, Blind and Disabled $2,958,934,744 74%All Claims (without Private Option or contracts) $4,023,136,382 100%

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ABD Direct and Halo Costs 74% of Traditional Medicaid

Elderly

Devel-opmen-tal Dis-ability

Behavioral Health

Other than ABD

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Nearly Half of Medicaid is for Long Term Services and Support (LTSS)*

*Includes Institutional and HCBSNote: TSG analysis of data covering calendar 2014

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Eldercare• Elder care including Halo is $1.2 billion, 29% of Medicaid• 65% of Elder LTSS is for Nursing Homes• Depending on Elder program, Halo Costs add 10-60% in other

medical costs • Nursing home costs are over 3x waiver costs per person• Even after adding halo costs, Waiver Beneficiaries across the

board, including those in the assisted living waiver claim less than half of institutional beneficiaries

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Elderly Care is Largely for Private Nursing Homes

58 - Private SNF $605,391,71853 - Personal Care - Regular $98,025,95697 - Elders Choices Waiver $53,130,71363 - Public SNF $39,695,754H2 - Nursing Home Hospice $29,971,17459 - Private SNF Crossover $24,963,236L4 - APD Agency Attendant Care, Co Employer $23,085,386L1 - APD Attendant Care $21,072,004I0 - Independent Choices Treatment Elderly $19,961,565AL - Assisted Living Facility $17,809,23624 - Home Health Services $16,791,790SR - AR Seniors $7,422,863PP - PACE $6,387,96673 - Private Duty Nursing EPSDT $6,025,448H1 - Hospice $5,947,01194 - EPSDT Prosthetic Device $5,714,59274 - Private Duty Nursing Services $3,063,530I9 - Independent Choices C/FI $1,862,990C3 - CSMT Age 60 and Older $1,678,375I8 - Independent Choices FMS Services $1,326,548I2 - Independent Choices New Trtmnt Elderly $193,673AX - Extension of 3 Prescriptions for Assisted Living $59,359

$989,580,886

Note: TSG analysis of data covering calendar 2014

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Halo Effect Accounts for Significant Costs for in Each Type of Elder LTSS


58 - Priv

ate SNF

63 - Public

SNF

97 - Elders

Choices W

aiver

AL - Assi

sted Li

ving Facil

ity

I0 - Independent C

hoices T

reatment E

lderly$0

$200,000,000

$400,000,000

$600,000,000

$800,000,000

Elder Care Program Costs

Direct Program Costs Other Medical

58 - Priv

ate SNF

63 - Public

SNF

97 - Elders

Choices W

aiver

AL - Assi

sted Li

ving Facil

ity

I0 - Independent C

hoices T

reatment E

lderly0%

20%40%60%80%

100%

Elder Care Program Costs


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Average Number of Elders in Care on Any Given Month Billing Medicaid

2014 Elder Headcount (mid-month)Average

2014Member Months

H1 - Hospice 140 1,67959 - Private SNF Crossover 1,582 18,982H2 - Nursing Home Hospice 604 7,24863 - Public SNF 237 2,84858 - Private SNF 11,544 138,53097 - Elders Choices Waiver 4,661 55,931I0 - Independent Choices Treatment Elderly 1,853 22,23053 - Personal Care - Regular 11,674 140,092AL - Assisted Living Facility 775 9,299


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Nursing Home HCBS$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

Per Capita Elder Care Costs: Nursing Home compared to HCBS


Nursing Home Costs are Twice as Much as HCBS


58 - Priv

ate SNF

63 - Public

SNF

97 - Elders

Choices W

aiver

AL - Assi

sted Li

ving Facil

ity

I0 - Independent C

hoices T

reatment E

lderly$0

$40,000$80,000

$120,000$160,000$200,000

Elder per Capita Care Program Costs

Direct Program CostsDirect Program Costs

$63,649

$27,176

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Developmental Disabilities• DD beneficiaries account for $900 million, 23% of traditional

Medicaid • Institutional DD including Halo effect costs Medicaid 2 – 3

times the cost of each HCBS program• Of that $900 Million, approximately $190 million is spent on

Children’s services

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Disability Includes Many Services for the Physically and Cognitively Disabled

D1 - DDS Alternative Com Service Waiver $196,507,98062 - Public ICF Intellectual Disabilities $158,927,86808 - Disabled Day Treatment Clinic Svc $154,045,71271 - EPSDT CHMS $59,971,53627 - ICF/INF/E.S. 24,594,45015 - EPSDT Screening 18,511,306E4 - Speech and Language Therapy - CHMS 16,084,798T7 - DDTCS Transportation 15,502,254E3 - Occupational Therapy - CHMS 12,873,920E2 - Physical Therapy - CHMS 11,201,996D7 - Rehab Servies School Based CHMS 9,917,245C7 - Speech and Language Therapy School Based Only9,345,225C6 - Occupational Therapy School Based Only 8,085,287C5 - Physical Therapy School Based Only 4,583,06014 - EPSDT Immunizations 4,180,774I1 - Independent Choices Trtmnt Young Disable 3,254,075AW - Autism Intensive Intervention Provider 2,711,72095 - EPSDT Orthotic Appliances 2,442,558D3 - Developmental Rehab Services 1,783,671D4 - DYS Rehab Services 1,712,93788 - Inpatient AR Teaching Crossover 1,649,49872 - EPSDT Podiatry 1,396,968C9 - Personal Care - School Based 1,124,60893 - EPSDT DMS Expansion 1,050,666RC - RSPD/ Residential Rehab Center 832,738T4 - TCM/DYS 741,476I3 - Independent Choices New Trtmnt Yng Dsbl 384,60180 - Therapy School District/ Esc Group 74,989

723,493,917


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Institutional DD: Direct and Halo Costs

27 - ICF/INF/E.S. 62 - Public ICF Intellectual Disabilities

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Direct Program Costs; 24,747,074

Direct Program Costs;

152,161,856

Other Medical Costs

Total Institutional DD Costs Including Halo Costs

Direct Program Costs Other Medical Costs

27 - ICF/INF/E.S. 62 - Public ICF Intellectual Disabilities0

20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

120,000,000

140,000,000

160,000,000

180,000,000

Direct Program Costs; 24,747,074

Direct Program Costs;

152,161,856

Institutional DD Costs Including Halo Costs

Direct Program Costs Other Medical Costs

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DD HCBS: Direct and Halo Costs by Program

27 - ICF/IN

F/E.S.

62 - Public

ICF M

entally Retarded

08 - Disa

bled Day Treatm

ent Clin

ic Svc

D1 - DDS Alte

rnative Com Servi

ce W

aiver

D6 - Rehab Servi

ces -

School B

ased RSPMI

D7 - Rehab S

ervies S

chool B

ased CHMS

0%20%40%60%80%

100%

DD Program Costs

Direct Program Cost Other Medical

$0$100,000,000$200,000,000$300,000,000$400,000,000

DD Program Costs

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Average Number of People in DD Care on Any Given Month Billing Medicaid

DD Waiver--headcount Average

2014Member Months

08 - Disabled Day Treatment Clinic Svc 10,122 121,46371 - EPSDT CHMS 4,262 51,144D1 - DDS Alternative Com Service Waiver 3,886 46,634D6 - Rehab Services - School Based RSPMI 482 5,783D7 - Rehab Services School Based CHMS 573 6,307E7 - Speech and Language Therapy - RSPMI 25 252

2014 Headcount Average

2014Member Months

27 - ICF/INF/E.S. - Pediatric 202 2,41862 - ICF Intellectual Disabilities 1,238 14,853Total Institutional 1,439 17,271


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Public and Private Institutions (ICF/DD) Account for 25% of All DD Cost Including Children and Adults


$0

$100,000,000

$200,000,000

$300,000,000

$400,000,000

$500,000,000

$600,000,000

$700,000,000

$800,000,000

Home and Community

(Children and adults)

Institutional

Disability Claims

$0

$20,000,000

$40,000,000

$60,000,000

$80,000,000

$100,000,000

$120,000,000

$140,000,000

$160,000,000

$180,000,000

$200,000,000

62 - ICF Intel-lectual Disabil-ities (Public &

Private)

27 - ICF/INF/E.S. (Pediatric)

DD Institutional Claims

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$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

$160,000

Per Capita DDCosts: ICF/DD compared to HCBS

Direct Program Cost

Other Medical

Institutional DD with Direct Costs and Halo Costs are Twice HCBS


$135,162

$68,937

$44,567 $45,937 $36,356

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Comparing per Person Adult ICF to Community Waiver

62 - ICF MR (Public and Private)

D1 - DDS Alternative Com Service Waiver

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

122,934

50,866

7,727

18,071

ICF/MR compared to Community Waiver--Per Capita


$130,661

$68,937

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Comparing per Person Pediatric ICF to CHMS

27 - ICF/INF/E.S. D7 - Rehab Servies School Based CHMS

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

122,814

17,587

39,995

28,350

Pediatric ICF compared to CHMSPer Capita


$162,809

$45,937

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There are 2,640 people on the Adult DD Waitlist. Many are Receiving Some Services

Note: TSG analysis of data covering 1/1/2014-6/30/2015: annualized by 12/18 months

08 - DDTCS

62 - Public—ICF/MR

56 - Pre-

scrip-tion

services

75 - Pediatric in-patient hospital

27 - ICF/

Inf/E.S.

Other

Medicaid Claims for Wait-listed Benefi-ciaries

Claims TotalBenefi-ciaries

08 - DDTCS 5,776,912 779

62 - Public—ICF/MR 5,065,694 52

56 - Prescription services 3,997,213 2,074

75 - Pediatric inpatient hospital 2,754,106 193

27 - ICF/Inf/E.S. 2,331,912 31

73 - Private duty nursing EPSDT 1,249,047 21

12 - Durable medical equipment/oxygen 1,121,738 1,140

T7 - DDTCS transportation 904,083 425L4 - APD Agency Attendant Care, Co-Employer 888,025 42

B5 - Speech and Language Therapy General 765,035 491

33 - Inpatient Psychiatric U21 718,402 47

53 - Personal Care - Regular 668,448 231

Other 5,753,848

Total31,994,46

2 2,640

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Most Frequent Types of Claims for Wait-Listed Beneficiaries

Note: TSG analysis of data covering 1/1/2014-6/30/2015

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Example of Waitlist Beneficiary Claims

L1 - APD Attendant Care $23,677.92

08 - DDTCS $12,783.60

12 - Durable medical equipment/oxygen other criteria: EPSDT referral indicator equals no. $2,871.30

T7 - DDTCS transportation $2,460.60

L6 - APD Counseling Case Management $1,190.00

45 - Oral surgery—physicians codes $611.80

54 - Physician crossovers $231.28

NT - Non-emergency transportation (NET broker) managed care w aiver $138.34

44 - Optometrist/occularist $49.22

16 - Eyeglasses $25.00

49 - Other practitioner crossovers $19.75

$44,058.81

12 - Durable medical equipment/oxygen other criteria: EPSDT referral indicator equals no. $7,125.36

C5 - Physical Therapy School Based Only $6,760.16

C6 - Occupational Therapy School Based Only $5,147.20

56 - Prescription services $5,135.88

C7 - Speech and Language Therapy School Based Only $4,330.24

08 - DDTCS $1,266.36

95 - Orthotic appliances EPSDT. Other criteria: TOS = 6 $1,066.90

55 - Physician services $543.65

PE - Pediatric outpatient hospital $503.00

70 - Surgery $383.36

02 - Ambulance $322.75

T1 - TCM/CMS $268.36

04 - Audiologist – General $109.23

80 - Therapy school district/ESC group $98.88

NT - Non-emergency transportation (NET broker) managed care w aiver $76.01

51 - Outpatient hospital $61.57

M3 - PCMH Care Coordination Payments $57.18

15 - EPSDT screenings With Other Criteria: $56.41

M1 - PCCM managed care fee $54.00

14 - EPSDT immunizations w ith Other Criteria: $9.56

$33,376.06

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Key Facts to Consider When Allocating Funds for Wait List Removal • Ensure that funding requested takes into consideration the

cost of community services that are already being rendered• Ensure that payment for “supportive living” is appropriate • Ensure right service, right time and right place – reason why

the standardized assessment is so important to the entire LTSS system

• Question whether the 20% administrative costs for providers is appropriate – (incentives not always aligned with needs)

• Can the 4265 Waiver cap be eliminated under a more global Section 1115 Waiver without costing more

• Global 1115 Waiver could integrate “supportive living” and “supportive employment” with flexibility to meet needs

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Behavioral Health

• RSPMI and Inpatient Psych account for $900 million, 22% of traditional Medicaid

• Total claims for RSPMI are twice those for In-Patient Psych, although average RSPMI claims are less than 1/10th average In-Patient Psych claims

• RSPMI is not a tradeoff for In-Patient Psych. Actually, high RSPMI is connected with even higher In-Patient Psych

• A few beneficiaries account for a large share of RSPMI

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Behavioral Health is Largely RSPMI and Inpatient Psych (under 21)

Behavioral Health Calendar 201436 - Community Mental Health (RSPMI) $310,700,13433 - Inpatient Psychiatric u-21 $145,777,45781 - Psychologist 1,760,192L6 - APD Counseling Case Management 1,751,957D6 - Rehab Services - School Based RSPMI 1,643,14732 - Inpatient Psychiatric Crossover u-21 1,527,431L2 - APD-Environmental Adaptations 753,91582 - Therapy Individual/Regular Crossover 324,484SO - Sexual Offender Program 146,952L5 - APD Traditional Agency Attendant Care 146,646SA - Substance Abuse Treatment Services 77,408T6 - School-Based Mental Health Services 38,516E7 - Speech and Language Therapy - RSPMI 38,270

$464,686,509


$0

$50,000,000

$100,000,000

$150,000,000

$200,000,000

$250,000,000

$300,000,000

$350,000,000

$400,000,000

$450,000,000

$500,000,000

36 - Com-munity Men-

tal Health (RSPMI);

$310,700,134

33 - Inpatient Psychiatric u-

21; $145,777,45

7

Other

Behavioral Health

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While More is Claimed for RSPMI, Average Inpatient Psych is Much Higher


$0

$100,000,000

$200,000,000

$300,000,000

$400,000,000

$500,000,000

$600,000,000

$700,000,000

Inpatient Psych;

$273,351,105

RSPMI; $351,570,34

0

Total Inpatient Psych and RSPMI Claims

RSPMI Inpatient Psych$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

$50,000

$3,878

$44,900

Average Claims per Person

Mill

ions

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Most Beneficiaries Claimed Less than $1,000 in 2014 for RSPMI


$1,000$2,000

$3,000$4,000

$5,000$6,000

$7,000$8,000

$9,000

$10,000

$11,000

$12,000

$13,000

$14,000

$15,000

$16,000

$17,000

$18,000

$19,000

$100,000

$500,0000

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

41%

17%

10%

Frequency of RSPMI Claim Amounts per Person

Annual Claims (< amount shown)

Num

ber o

f Ben

eficia

ries

Axis

Title

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Top Quartile RSPMI Beneficiaries Claim 75% of RSPMI and 56% of IP Psych

Low-level RSPMI beneficiaries use little IP Psych;High-level RSPMI beneficiaries claim a lot of IP Psych

Overall Average

1st Quartile of RSPMI

4th Quartile of RSPMI Amount % Amount % Amount %

RSPMI $3,878 $281 $11,587 $351,570,340 100% $6,382,127 2% $262,621,236 75%Inpatient Psych $44,900 $105 $47,083 $273,351,105 100% $9,913,512 4% $152,312,848 56%

Total of ClaimsOverallAverage Claims Amount 1st Quartile 4th Quartile


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634 Beneficiaries Claim More than $100 RSPMI per Day, Totaling $32 MM


3,000 - 4,000

4,000 - 5,000

5,000 - 6,000

6,000 - 7,000

7,000 - 8,000

8,000 - 9,000

9,000 - 1,0000

10,000 - 20,000

0

50

100

150

200

250

300

350

400340

176

91

21 4 0 1 1

Top RSPMI Beneficiaries

Monthly $Claims Amount for RSPMI

Num

ber o

f Ben

efici

arie

s

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Community First Choice Option: 1915 (k): ACA Section 2401• Optional new state flexibility in providing HCBS services• CFCO is a state plan amendment resulting in an entitlement• Provides states enhanced 6% FMAP for “amounts expended

under section 1915 (k)”• Is not a “pass” on Olmstead related requirements• No prohibition from individuals receiving 1915 (c), Money

Follows the Person, and CFC services at the same time

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Community First Choice Option• Permits states to combine three 1915 (c) waiver populations

under 1915 (k) state plan amendment• Maintenance of Effort in first year must maintain same amount

or exceed spending in prior 12 month period before CFCO start date

• CMS estimated 25 states would choose CFCO option; to date 6 states have started CFCO

• SPAs do not expire; to change or eliminate an existing SPA requires a modified SPA request for CMS approval

• CMS must submit evaluation report on the effectiveness, impact, and comparative costs of CFCO to Congress on 12/31/15

• States can design HCBS services similar to CFCO under an 1115 waiver that does not result in a new entitlement (e.g. TennCare)

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States that have implemented CFCO• California: 7/1/2013: Limits services to 283 hours per month• Maryland: 1/1/2014: Cost caps on non-HCBS services (home

delivered meals; assistive technology, environmental assessments)

• Montana: 10/1/2013: Limits attendant services to 84 hours every two weeks; IADL services not to exceed 1/3rd total CFC hours or 10 hours per two week period; skills acquisition not to exceed 25 hours every three months

• Oregon: 7/1/2013: Cost caps on home modifications and assistive technology; 18 outcome measures

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States that have implemented CFCO• Washington: 8/30/2015: Functional eligibility for Personal

Care is higher; reinvest savings to address DD waiting list• Texas: 6/1/2015: Retained existing Personal Care and 1915 (c)

waivers for I/DD population; persons receiving HCBS (c) services through Star Plus managed care ineligible for CFCO

Government & Nonprofit

Arkansas Health Care Reform Task Force: TSG Status Update # 4